PERIOPERATIVE NURSING

Kennedy C. Bangan, RN, MSN, HAAD-RN

 DEFINITION OF TERMS
• SURGERY
o It is the branch of medicine concerned with diseases and
conditions which require or are amenable to operative procedures.
Surgery is the work done by a surgeon.
o It involve cutting, abrading, suturing, laser or otherwise physically
changing body tissues and organs.
• SURGEON
o A physician who treats disease, injury, or deformity by operative or
manual methods.
o A medical doctor specialized in the removal of organs, masses and
tumors and in doing other procedures using a knife (scalpel)
• STERILE
o Free from living germs or microorganisms aseptic sterile surgical
instruments.
 DEFINITION OF TERMS
• ASEPSIS
o The state of being free of pathogenic microorganisms.
o The process of removing pathogenic microorganisms or protecting
against infection by such organisms.

• SEPSIS
o A toxic condition resulting from the spread of bacteria or their
toxic products from a
o Focus of infection especially septicemia
o Is a severe illness caused by overwhelming infection of the
bloodstream by toxin-producing bacteria.
o Is caused by bacterial infection that can originate anywhere in the
body.
 DEFINITION OF TERMS
• DISINFECTANT
o Any chemical agent used chiefly on inanimate objects to destroy or
inhibit the growth of harmful organisms.
• ANTISEPTIC
o Is a substance that prevents or arrests the growth or action of
microorganisms either by inhibiting their activity or by destroying
them. The term is used especially for preparations applied topically
to living tissue
• STERILIZATION
o The destruction of all living microorganisms, as pathogenic
bacteria, vegetative forms, and spores.
 PREFIXES & SUFFIXES

o PREFIXES
TERMS MEANING TERMS MEANING
Supra above beyond Nephro kidney
Ortho joint Neuro nerve
Chole bile or gall Oophor ovary
Cysto bladder Pneumo lungs
Encephalo brain Pyelo kidney pelvis
Entero intestine Salphingo fallopian tube
Hystero uterus Thoraco chest
Mast breast Viscero organ esp. abdomen
Meningo membrane meninges Cranio skull
Myo muscle
 PREFIXES & SUFFIXES

o SUFFIXES
TERMS MEANING
-oma tumor swelling
-ectomy removal of an organ or gland
-rhapy suturing or stitching of a part or an organ
-scopy looking into
-ostomy making an opening or a stoma
-otomy cutting into
-plasty to repair or restore
-cele tumor, hernia, swelling
-itis inflammation of
 PERIOPERATIVE NURSING

o a.k.a OPERATING ROOM NURSING

o The identification of physiological

sociological needs of the client, the
implementation of an individualized
program of nursing care in order to
restore or maintain the health welfare of
the patient before, during, and after the
surgical intervention.
 PERIOPERATIVE NURSING

Philosophy

To give service that aims to provide

comprehensive support physically, morally,
psychologically, spiritually, socially to a
patient undergoing surgery.
 PERIOPERATIVE NURSING
To assist the surgeon by
functioning effectively
as a member of the
surgical team.

To create
maintain an To provide safe,
aseptic / supportive
GOAL comprehensive
sterile
environment. care.
 CLASSIFICATIONS OF SURGERY
o According to URGENCY

• EMERGENT
 Patient requires immediate attention
disorder maybe life- threatening.
 Indications for surgery without delay.
 Examples:
 Severe bleeding
 Extensive
 Burns
 Bladder or intestinal obstruction
 Fractured skull
 Gunshot or Stab wounds.
CLASSIFICATIONS OF SURGERY
 CLASSIFICATIONS OF SURGERY
• URGENT
 Patient requires prompt attention.
 Indications for surgery within 24-30 hours.
 Examples:
 Acute gallbladder infection
 Kidney/Ureteral stones
 Appendicitis
 CLASSIFICATIONS OF SURGERY
• REQUIRED
 Patient needs to have surgery.
 Indications for surgery plan within few weeks
or months.
 Examples:
 Prostatic hyperplasia without bowel obstruction
 Thyroid disorders
 Cataracts
 CLASSIFICATIONS OF SURGERY

• ELECTIVE
 Patient should have surgery.
 Indications for surgery Failure to have
surgery not catastrophic.
 Examples:
 Repair of scars
 Simple hernia
 Vaginal repair
 CLASSIFICATIONS OF SURGERY
• OPTIONAL
 Decision rests with patient
 Indications for surgery personal preference
 Examples:
 Cosmetic surgery
 CLASSIFICATIONS OF SURGERY
o According to DEGREE OF RISK

• MAJOR
 High degree of risk
 Maybe complicated / prolonged, large losses
of blood may occur, vital organs maybe
involved, post-op complications may be
likely.
 Examples:
 Removal of kidney
 Organ transplant
 Open heart surgery
 CLASSIFICATIONS OF SURGERY

• MINOR
 Little risk with few complications.
 Often performed in a day surgery.
 Examples:
 Excision biopsies
 Cauterizations of warts
 Endometrial/Endocervical biopsy
 Circumcision
 Incision & drainage
 Ungiectomy
 CLASSIFICATIONS OF SURGERY
o According to PURPOSE

• DIAGNOSTIC
 Verifies suspected diagnosis
 Example: Biopsy
• EXPLORATORY
 Estimates the extent of the disease or
injury.
 Example: Exploratory laparotomy
• CURATIVE
 Removes or repairs damaged tissues.
 Example: Appendectomy
 CLASSIFICATIONS OF SURGERY

• ABLATIVE
 Removing diseased organ that cannot
wait anymore.
 Emergency surgery.
• PALLIATIVE
 Relieves symptoms but does not cure the
underlying disease process.
• RECONSTRUCTIVE
 Partial or complete restoration of a
damaged organ/tissue to bring back the
original appearance function.
 CLASSIFICATIONS OF SURGERY

• CONSTRUCTIVE
 Repairing the damaged tissue or
congenitally defective organ.
 CLASSIFICATIONS OF SURGERY
o According to LOCATION

• INTERNAL
 Inside the body.
 Example: Hysterectomy

• EXTERNAL
 Outside the body.
 Example: Skin grafting
FOUR BASIC PATHOLOGIC CONDITIONS THAT
REQUIRE SURGERY
o OBSTRUCTION
 a blockage are dangerous because they block
the flow of blood, air, CSF, urine, bile through
the body.
o PERFORATION
 is a rupture of the organ, artery or bleb.
o EROSION
 break in the continuity of tissue surface. It can
be caused by irritation, infection, ulceration or
inflammation.
o TUMOR
 abnormal growth of tissue that serves no
physiologic function in the body.
 THE SURGICAL RISK PATIENTS

o Extremes of age ( very young very old )

o Extremes of weight (emaciation, obesity)
o Dehydrated patients
o Nutritional deficits
o Patients with severe trauma or injury,
infection/sepsis
o Patients with cardiovascular disease
o Endocrine dysfunction (diabetes mellitus)
o Hypertensive hypotensive patients
o Hypovolemia
o Hepatic disease
o Preexisting mental or physical disability
 PROBLEMS MAY ARISE IN SURGERY

o Surgical risk patients probability of morbidity or

mortality following surgery
o Pain
o Hemorrhage
o Surgical site infection
o Urinary tract infection
 THREE PHASES of PERIOPERATIVE NURSING
Period of time Period of time Period of time

PREOPERATIVE

POSTOPERATIVE
INTRAOPERATIVE
from the from that
decision for when the patient begins with
surgery until the is transferred to admission to the
patient is the operating PACU and ends
transferred into room to the with
the operating admission to follow-up
room. post-anesthesia evaluation in the
care unit clinical setting or
(PACU). at home.
 PREOPERATIVE NURSING ACTIVITIES

 Assessment of the client (baseline evaluation of

the pt. before the day of surgery-interview)
 Identification of potential/actual health problems.
 PREADMISSION TESTING- ensure necessary tests
have been performed
 Pre-op teaching involving client support persons.
 Day of surgery
• Patient teaching reviewed
• Informed consent confirmed
• Patients identity surgical site verified
• IVF started.
 PREOPERATIVE NURSING ACTIVITIES
o Preparation for Surgery
 Psychological Support
 Assess clients fears, anxieties, support
systems patterns of coping.
 Establish trusting relationship with client
 significant others.
 Explain routine procedures, encourage
verbalization of fears allow client to ask
questions.
 Demonstrate confidence in surgeon staff.
 Provide for spiritual care if appropriate.
 PREOPERATIVE NURSING ACTIVITIES
o Preoperative Teaching
 Frequently done on an outpatient basis.
 Assess client’s level of understanding of surgical procedure
its implications.
 Answer questions, clarify reinforce explanations given by
the surgeon.
 Explain routine pre- post-op procedures any special
equipment to be used.
 Preoperative experience
 Preoperative medication
 Breathing exercises, coughing, incentive spirometer
 Leg exercises
 Position changes and movement
 Pain management
 Reducing anxiety and fear, support of coping
PREOPERATIVE NURSING ACTIVITIES
 PREOPERATIVE NURSING INTERVENTIONS
o Physical Preparations
 Patient safety is a primary concern.
 Obtain history of past medical conditions, surgical
procedures, dietary restrictions medications.
 Perform baseline head-to-toe assessment, including VS,
height & weight.
 Ensure that diagnostic procedures pertinent to surgery are
performed as ordered.
• CBC
• Electrolytes
• PT/PTT (Prothrombin Time/Partial thromboplastin
time)
• Urinalysis
• ECG
• Blood typing & crossmatch
 PREOPERATIVE NURSING INTERVENTIONS
o Physical Preparations
 NPO
 Bowel prep and skin prep
• cleansing enema or laxative before surgery to allow
satisfactory visualization of the surgical site.
• goal of pre-op skin prep is to decrease bacteria
without injuring the skin.
 Immediate preoperative preparation
 Complete checklist and chart
 Hospital gown, voiding, removal of dentures, jewelry,
contacts, etc.
 Preoperative medication
 Transporting the pt. to the Presurgical area about 30 to 60
minutes before anesthetics is to be given.
 Attend to family needs
 PREOPERATIVE NURSING INTERVENTIONS
o Legal Preparations
 Surgeon obtains operative permit (informed consent)
 Surgical procedures, alternatives, possible complications
disfigurements or removal of body parts are explained.
 It is part of the nurses role as client advocate to confirm
that the client understands information given.
 PREOPERATIVE NURSING INTERVENTIONS
o Informed Consent
 Invasive procedures, such as surgical incisions, biopsy,
cystoscopy or paracentesis.
 Procedures requiring sedation or anesthesia
 A non-surgical procedure, such as arteriography
 Procedures involving radiation
 Adult client (over 18 y/o) signs own permit unless
unconcious or mentally incompetent.
 If unable to sign, relative (spouse or next of kin) or
guardian will sign.
 In an emergency, permission via telephone or telegram
is acceptable have a 2nd listener on phone when
telephone permission is given
 PREOPERATIVE NURSING INTERVENTIONS
o Informed Consent
 Consents are not needed for emergency care if all four (4)
of the ff. criteria are met
• There is an immediate threat to life.
• Experts agree that it is an emergency.
• Client is unable to consent.
• A legally authorized person cannot be reached.
 Minors (under 18 y/o) must have consent signed by an adult
(i.e. Parent or legal guardian)
 Emancipated minor (married or independently earning his
or her own living) may sign his/ her own consent.
 Witness to informed consent may be a nurse, another M.D.,
clerk or any other authorized person.
 The nurse witnessing informed consent, specifies whether
witnessing explanation of surgery or just signature of the
client.
 PREOPERATIVE MEDICATIONS
o Purpose
 To relieve fear anxiety.
 To reduce dose needed for induction maintenance of
anesthesia.
 To prevent reflex bradycardia that happens during induction
of anesthesia.
 To minimize oral secretions.
 INTRAOPERATIVE NURSING ACTIVITIES

 Activities providing for patient’s safety.

 Maintenance of aseptic environment.
 Ensuring proper function of equipment.
 Providing surgeons with specific instruments
supplies for surgical field.
 Completing documentation.
 Positioning patients.
 Acting as scrub/circulating nurse.
 MEMBERS OF THE SURGICAL TEAM

 Patient
 Anesthesiologist or anesthetist
 Surgeon
 Nurses (Scrub & Circulating)
 Surgical technologists
 THE SURGICAL TEAM AT WORK

 Patient
• the most
important
member of the
surgical team.
• may feel relaxed
prepared, or
fearful highly
stressed.
• is also subject to
several risks.
 THE SURGICAL TEAM AT WORK

 Surgeon
• performance of
operation.
• post-op
management/care
• assumes all
responsibility for all
medical acts of
judgement
management.
 THE SURGICAL TEAM AT WORK

 Anesthesiologist/
Anesthetist
• administers the
anesthetic agent
• monitors the
patient’s physical
status throughout
the surgery.
 THE SURGICAL TEAM AT WORK

 Scrub Nurse
• provides sterile
instruments
• supplies to the
surgeon during the
procedure.
• performs surgical
hand scrub.
 THE SURGICAL TEAM AT WORK

 Circulating Nurse
• coordinates the care
of the patient in the
O.R.
• care provided
includes assisting with
patient positioning ,
skin prep, managing
surgical specimens
documenting
intraoperative events.
 THE SURGICAL TEAM AT WORK

 Circulating Nurse
• coordinates the care
of the patient in the
O.R.
• care provided
includes assisting with
patient positioning ,
skin prep, managing
surgical specimens
documenting
intraoperative events.
 PREVENTION OF INFECTION

 The surgical environment stark appearance cool

temperature. Located central to all supporting
services.
 Unrestricted zone where street clothes are
allowed.
 Semi-restricted zone where attire consists of scrub
clothes caps.
 Restricted zone where scrub clothes, shoe covers,
caps masks are worn.
The OPERATING ROOM
The OPERATING ROOM
 BASIC GUIDELINES FOR SURGICAL ASEPSIS

 All materials in contact with the wound and within

the sterile field must be sterile.
 Gowns are sterile in the front from chest to the
level of the sterile field, and sleeves from 2 inches
above the elbow to the cuff.
 Only the top of a draped table is considered sterile.
During draping, the drape is held well above the
area and is placed from front to back.
 Items are dispensed by methods to preserve
sterility.
 Movements of the surgical team are from sterile to
sterile and from unsterile to sterile only.
 BASIC GUIDELINES FOR SURGICAL ASEPSIS

 Movement around the sterile field must not cause

contamination of the field. At least a 1- foot
distance from the sterile field must be maintained.
 Whenever a sterile barrier is breached, the area is
considered contaminated.
 Every sterile field is constantly maintained and
monitored. Items of doubtful sterility are
considered unsterile.
 Sterile fields are prepared as close as possible to
time of use.
 SURGICAL ASEPTIC TECHNIQUE

 BEFORE AN OPERATION
• It is necessary to sterilize and keep sterile all
instruments, materials, and supplies that
come in contact with the surgical site.
• Every item handled by the surgeon and the
surgeon's assistants must be sterile.
• The patient's skin and the hands of the
members of the surgical team must be
thoroughly scrubbed, prepared, and kept as
aseptic as possible.
 SURGICAL ASEPTIC TECHNIQUE

 DURING THE OPERATION

• The surgeon, surgeon’s assistants, and the
scrub nurses must wear sterile gowns and
gloves and must not touch anything that is
not sterile.
• Maintaining sterile technique is a
cooperative responsibility of the entire
surgical team.
• Each member must develop a surgical
conscience, a willingness to supervise and be
supervised by others regarding the
adherence to standards.
 BASIC PRINCIPLES OF SURGICAL ASEPSIS

 All personnel assigned to the operating room must practice

good personal hygiene. This includes daily bathing and
clothing change.
 Those personnel having colds, sore throats, open sores,
and/or other infections should not be permitted in the
operating room.
 Operating room attire (which includes scrub suits, gowns,
head coverings, and face masks) should not be worn outside
the operating room suite. If such occurs, change all attire
before re-entering the clean area. (The operating room and
adjacent supporting areas are classified as "clean areas.")
 All members of the surgical team having direct contact with
the surgical site must perform the surgical hand scrub before
the operation.
 BASIC PRINCIPLES OF SURGICAL ASEPSIS

 All materials and instruments used in contact with the site

must be sterile.
 The gowns worn by surgeons and scrub corpsmen are
considered sterile from shoulder to waist (in the front only),
including the gown sleeves.
 If sterile surgical gloves are torn, punctured, or have touched
an unsterile surface or item, they are considered
contaminated.
 The safest, most practical method of sterilization for most
articles is steam under pressure.
 Label all prepared, packaged, and sterilized items with an
expiration date.
 Use articles packaged and sterilized in cotton muslin
wrappers within 28 calendar days.
 BASIC PRINCIPLES OF SURGICAL ASEPSIS

 Use articles sterilized in cotton muslin wrappers and sealed in

plastic within 180 calendar days
 Unsterile articles must not come in contact with sterile
articles.
 Make sure the patient's skin is as clean as possible before a
surgical procedure.
 Take every precaution to prevent contamination of sterile
areas or supplies by airborne organisms.
 HANDLING STERILE ARTICLES/ITEMS

 When you are changing a dressing, removing sutures, or

preparing the patient for a surgical procedure, it will be
necessary to establish a sterile field from which to work. The
field should be established on a stable, clean, flat, dry
surface.
 An article is either sterile or unsterile there is no in-between.
If there is doubt about the sterility of an item, consider it
unsterile
 Any time the sterility of a field has been compromised,
replace the contaminated field and setup.
 Do not open sterile articles until they are ready for use.
 Do not leave sterile articles unattended once they are
opened and placed on a sterile field.
 HANDLING STERILE ARTICLES/ITEMS

 Do not return sterile articles to a container once they have

been removed from the container.
 Never reach over a sterile field.
 When pouring sterile solutions into sterile containers or
basins, do not touch the sterile container with the solution
bottle. Once opened and first poured, use bottles of liquid
entirely. If any liquid is left in the bottle, discard it.
 Never use an outdated article. Unwrap it, inspect it, and, if
reusable, rewrap it in a new wrapper for sterilization.
SURGICAL HAND SCRUB, GOWNING, &
GLOVING
 ANESTHESIA

 ANESTHESIA
• is a state of narcosis, analgesia, relaxation
reflex loss.
• involves the use of medications that block
pain sensations (analgesia) during surgery
and other medical procedures.
• Anesthesia also reduces many of your body’s
normal stress reactions to surgery.
 TYPES OF ANESTHESIA

o GENERAL ANESTHESIA
• Affects your entire body and renders you
unconscious.
• The patient would be completely unaware
and not feel pain during the surgery or
procedure.
• Also causes forgetfulness (amnesia) and
relaxation of the muscles throughout your
body.
• Suppresses many of your body’s normal
automatic functions.
Anesthesia Machine
 Stages of General Anesthesia

o Stage 1: Beginning anesthesia

• Warmth, dizziness , feeling of detachment.
• Ringing, roaring or buzzing in the ears.
• Still conscious but may sense inability to
move the extremities easily.
• Noises are exaggerated even low voices or
minor sounds seem loud unreal.
• Unnecessary noises motions should be
avoided.
 Stages of General Anesthesia

o Stage 2: Excitement
• Struggling, shouting, talking, singing,
laughing or crying (avoided if given smoothly
quickly)
• Pupils dilate ( but contract if exposed to
light)
• PR rapid RR irregular.
• Restraining the patient may be possible.
 Stages of General Anesthesia

o Stage 3: Surgical anesthesia

• Reached by continuous administration of
anesthetic vapor or gas.
• Patient is unconscious lies quietly.
• Pupils are small but contract when exposed
to light
• RR regular, PR volume WNL, skin pink/
flushed
 Stages of General Anesthesia

o Stage 4: Surgical anesthesia

• Reached when too much anesthesia has
been administered.
• Respirations shallow, pulse weak thready .
• Pupils widely dilated no longer contract
when exposed to light.
• CYANOSIS develops w/o prompt
intervention? DEATH
• Anesthetic is discontinued immediately.
• Circulatory support initiated.
 Types of Regional Anesthesia

o Epidural Anesthesia
• Commonly used conduction block
• Injecting a local anesthetic into the epidural space
that surrounds the dura matter of the SC.
• Blocks sensory, motor autonomic functions.
• Doses are much higher than spinal because epidural
anesthetic does not make direct contact w/ the SC or
nerve roots
 Types of Regional Anesthesia

o Spinal Anesthesia
• Local anesthetic is
introduced at the
lumbar level between
L4 L5.
• Produces anesthesia
of lower extremities,
perineum lower
abdomen.
• Knee chest position
 Types of Regional Anesthesia

o Peripheral Nerve Block

• A local anesthetic is injected near a specific nerve or
group of nerves to block pain from the area of the
body supplied by the nerve.
• Nerve blocks are most commonly used for procedures
on the hands, arms, feet, legs, or face.
 TYPES OF ANESTHESIA

o LOCAL ANESTHESIA
• Involves injection of a local anesthetic
(numbing agent) directly into the surgical
area to block pain sensations.
• It is used only for minor procedures on a
limited part of the body.
 Nursing Goals for the Patient in the
Intraoperative Period
 Reducing anxiety
 Preventing positioning injuries
 Maintaining patient safety
 Maintaining the patient's dignity
 Avoiding complications
WHO Surgical Safety Checklist
Protecting the Patient from Injury
CLASIFICATIONS OF SURGICAL INSTRUMENT

 Cutting and Dissecting

• These instruments usually have sharp edges
or tips to cut through skin, tissue and suture
material.
CLASIFICATIONS OF SURGICAL INSTRUMENT

 Clamping and Occluding

• Are used in many surgical procedures for
compressing blood vessels or hollow organs,
to prevent their contents from leaking.
CLASIFICATIONS OF SURGICAL INSTRUMENT

 Retracting and Exposing

• These surgical instruments are used to hold
back, or retract organs and tissue so the
surgeon has access to the operative area.
CLASIFICATIONS OF SURGICAL INSTRUMENT

 Grasping and Holding

• These instruments,
as their name
suggests, are used
to grasp and hold
tissue or blood
vessels that may
be in the way
during a surgical
procedure.
Types of Suture Materials
SURGICAL POSITIONS
POST-OPERATIVE NURSING ACTIVITIES in PACU

 Provide care for the patient until he/she has

recovered from the effects of anesthesia.
 Patient has resumption of motor and sensory
function, is oriented, has stable VS, and shows no
evidence of hemorrhage or other complications of
surgery.
 Frequent skilled assessment of the patient is vital
 Responsibilities of the PACU Nurse

 Review pertinent information and baseline

assessment upon admission to the unit.
 Assessments include airway and respirations,
cardiovascular function, surgical site, function of
the central nervous system also assess IV and all
tubes and equipment.
 Reassess VS and patient status every 15 minutes or
more frequently as needed.
 Provide report and transfer the patient to another
unit or discharge the patient to home.
 Maintaining a Patent Airway

 A primary consideration necessary to maintain

ventilation and oxygenation!
 Provide supplemental oxygen as indicated.
 Assess breathing by placing hand near face to feel
movement of air.
 Keep head of bed elevated 15-30o unless
contraindicated.
 May require suctioning.
 If vomiting occurs, turn patient to the side
THANK YOU!!!